• Admission Plan Eases Patient Transition and Care Coordination

    Lola Butcher

    Download a sample hospital admission plan of care that Southeast Texas Medical Associates developed to help coordinate patient care in the hospital.

    As a patient-centered medical home, Southeast Texas Medical Associates (SETMA) has long focused on its patients' transitions of care. The San Antonio-based multidisciplinary practice developed a hospital admission plan of care template to help patients transition into the hospital setting and communicate the physician's plan of care to the patient's care team. The physician practice recognizes that coordinating care from the outset is critical to patient outcomes.

    Access tool: SETMA Hospital Admission Plan of Care Document

    "This tool is intended to help address major problems that can stem from a lack of coordination, such as unnecessary days in the hospital, low patient satisfaction, re-hospitalizations, and inadequate staff communications," says James L. Holly, MD, SETMA's CEO.

    By helping all parties know what to expect during the hospitalization, the document helps the patient, family members, and caregivers start thinking about and planning for a successful discharge. SETMA's hospital admission plan of care was designed to answer common questions that patients and hospital staff have for the admitting physician. Shortly after admission, SETMA patients and hospital staff receive a personalized plan that lists the following items:

    • Admission diagnoses
    • Anticipated procedures, tests, and consultations
    • A reconciled medication list
    • Contact information for SETMA providers so that the patient and family have 24-hour access to the physician without having to go through an answering service or hospital staff

    A copy of the plan also goes into the patient's electronic health record (EHR) so all caregivers have access to it. The document can influence a patient's hospital experience in a number of ways, says Holly:

    • Guide the patient's expectations about length of stay, health outcomes, and the individuals who will be involved in providing care.
    • Help patients understand how to evaluate the quality of care they receive.
    • Allay patients' anxiety about being in the hospital by informing them of what to expect.
    • Communicate the care plan to all physicians and nurses who will work with the patient.

    A template for the hospital admission plan is built into SETMA's EHR system, which physicians can access in the four hospitals in which they practice. So creating the document adds little extra work for the admitting physician, Holly says.

    "The document is driven from the H&P [patient history and physical] so when the H&P is printed, the hospital plan of care is automatically printed," he says. "Without healthcare providers using an EHR in the hospital setting, which is linked to the ambulatory record, this would be difficult. With connectivity and linkage, it is simple."

    SETMA began using the hospital plan of care this summer, and early feedback has been good. "The nurses particularly like this," Holly says. "We have fewer complaints from patients that 'No one has told me anything about why I am here or what I can expect!'"

    Lola Butcher is a freelance writer and editor based in Missouri.

    Interviewed for this article:
    James L. Holly, MD, is adjunct professor at University of Texas Health Science Center-San Antonio, and CEO, Southeast Texas Medical Associates, Beaumont, Texas (jholly@setma.com).

    Access tool: SETMA Hospital Admission Plan of Care Document